An operating room 'black box' the future of surgical procedure

St Michael’s Hospital’s Dr. Teodor Grantcharov (centre) believes new technology can provide a “black box” recording of what goes on in the operating room, similar to the recording devices found in airliners today.

When a surgery goes wrong, how do doctors assess blame? How do they understand what went wrong so they can prevent it in the future? Currently, most hospitals have a reactive process: a weekly morbidity and mortality meeting where they discuss possible reasons for adverse outcomes – a tidy medical phrase that stands in for death, disability or prolonged hospital stay.

Since late April of this year, Teodor Grantcharov – a staff surgeon at Toronto's St. Michael's Hospital – has been trying something new. He wants surgery to look more like other high-performance, high-safety endeavours such as the airline industry, where data recording and constant analysis help to proactively minimize mistakes.

As such, in the specially equipped OR 8 at St. Michael's, Dr. Grantcharov records every step of his operations with a "black box" of his own design, a prototype that works with laparoscopic surgeries (the type where doctors push a video camera and small surgical tools inside the body to perform "minimally invasive" procedures). This black box records conversations between nurses and doctors, logs temperature and decibel levels, records the video feed from the surgical camera and also records a "gallery view" of the entire operating theatre, all in a package about the size of a PlayStation 3. He's looking for errors, for ways to improve, and one of the key tools will be familiar to professional athletes: film study.

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A panel of surgical experts reviews each surgery – Dr. Grantcharov performs about six a week – and time is of the essence because recordings are only kept for 30 days due to privacy constraints. The analysis of those recordings remains, and that's where all the critical details are captured.

"We define error as very very minor deviation from the perfect course," Dr. Grantcharov said. "People believe that surgeons are perfect and never make mistakes, and that's not true, as long as there are humans there will always be mistakes. We have to be more transparent about our business."

According to Dr. Grantcharov's research co-ordinator Karthik Raj, the team of 12 hopes to expand black boxes to urology and gynecology surgical teams, and to move beyond the laparoscopic limitations by incorporating such technology as Google Glass to log the surgeon's eye view of "open" procedures. The black box is also slated to be tested at two hospitals in Denmark (where he did his surgical residency) as well as in Chile, and there is some interest at U.S. hospitals.

But for Sacha Bhatia, director of the Institute for Health Systems Solutions and Virtual Care at Women's College Hospital, the key concern is how this data get used.

"The blame and shame question is a big one, and the big spectre of medical-legal," said Dr. Bhatia, who has advised Ontario's Ministry of Health and Long-Term Care on quality improvement policies. "If something happens, are these black boxes going to be used to potentially impact a legal case?" He offers the cautionary tale of public reporting of cardiac care outcomes in the U.S. For many years, it was practice to make public a list of surgeons and their success rates, but some researchers worried that the pressure of public exposure caused surgeons to avoid high-risk cases or to be more conservative in the operating theatre.

"I think you should use this stuff, but I think it should be kept within hospitals, and within the circle of care," Dr. Bhatia said.

Dr. Grantcharov is a believer. "I found the benefits of this in my own practice," he said. "I personally had a technique that I thought was great, but I found things I could do better."

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